eCLINICALWORKS HL7 R SPECIFICATION · The following table outlines the transaction structure section of the HL7 message: ... PID|1|7779|||Test^Test^||19670502|F||C|123 HIGH WAY^^Westboro^MA^01581||

© eClinicalWorks, 2015. All rights reserved.

eCLINICALWORKS HL7 REPORTS SPECIFICATION

ORU and MDM - April 2015

©Copyright eClinicalWorks, April 2015 - eClinicalWorks HL7 Reports Specification 2

CONTENTS HL7 REPORTS SPECIFICATIONS – ORU _____________________________________ 4

Transaction Structure _____________________________________________________________ 4

Message Delimiters ______________________________________________________________ 5

Conventions ____________________________________________________________________ 5

MSH – Message Header Segment ___________________________________________________ 5 Sample Output ______________________________________________________________________ 6

PID – Patient Identification ________________________________________________________ 6 Sample Output ______________________________________________________________________ 8

PV1 – Patient Visit _______________________________________________________________ 8 Sample Output ______________________________________________________________________ 9

ORC – Common Order Segment ____________________________________________________ 9 Sample Output _____________________________________________________________________ 10

OBR – Observation Request Segment _______________________________________________ 10 Sample Output _____________________________________________________________________ 11

OBX – Observation/Result Segment ________________________________________________ 12 Sample Output _____________________________________________________________________ 12

NTE – Notes and Comments ______________________________________________________ 12 Sample Output _____________________________________________________________________ 13

Sample 1 Report Message ________________________________________________________ 13


HL7 REPORTS SPECIFICATIONS – MDM ___________________________________ 17

Transaction Structure ____________________________________________________________ 17

Message Delimiters _____________________________________________________________ 18

Conventions ___________________________________________________________________ 18

MSH – Message Header Segment __________________________________________________ 18 Sample Output _____________________________________________________________________ 19

PID – Patient Identification _______________________________________________________ 19 Sample Output _____________________________________________________________________ 21

PV1 – Patient Visit ______________________________________________________________ 21 Sample Output _____________________________________________________________________ 22

TXA – Document Notification Segment _____________________________________________ 22 Sample Output _____________________________________________________________________ 23

OBX – Observation/Result Segment ________________________________________________ 24 Sample Output _____________________________________________________________________ 24


NTE – Notes and Comments ______________________________________________________ 24 Sample Output _____________________________________________________________________ 25


Appendix: Notices ______________________________________________________________ 28 Trademarks _______________________________________________________________________ 28


HL7 REPORTS SPECIFICATIONS – ORU

The HL7 reports specifications (ORU) described in this section for eClinicalWorks® are:

Transaction Structure ORC – Common Order Segment

Message Delimiters OBR – Observation Request Segment

Conventions MSH – Message Header Segment PID – Patient Identification PV1 – Patient Visit

OBX – Observation/Result Segment NTE – Notes and Comments Sample 1 Report Message Sample 2 Report Message

Transaction Structure The following table outlines the transaction structure section of the HL7 message:

Name Description Comments

MSH Message Header This segment should always be present in the ORU message

PID Patient Identification There should be a PID segment to give the patient demographic information

PV1 Patient Visit PV1 segment if present will be used for determining the Physician Information

ORC Common Order PV1 segment if present will be used for determining the Physician Information

OBR Observation Request Report type information is retrieved from this segment and is a required segment

OBX Observation Result Report detail information is retrieved from this segment

NTE Notes and Comments Report detail information is retrieved from this segment

Message Delimiters


Message Delimiters The following table outlines the message delimiters:

Character Function Character

Segment Terminator <CR> LF

Field Separator | (pipe)

Component Separator ^ (caret)

Repetition Separator ~ (tilde)

Conventions The following table outlines the conventions:


Required field – this should always be sent R

Optional field – this information will be processed if available O

Not Supported N

MSH – Message Header Segment The Message Header (MSH) segment defines the intent, source, destination, and some specifics of the syntax of a message:

Field Name Segment Name Comment Len R/O

Segment Type ID MSH.00 MSH 3 R

Encoding Characters MSH.01 ^~\& 4 R

Sending Application MSH.02 Sending Application 30 O

PID – Patient Identification



Sending Facility MSH.03 Sending Facility 30 O

Receiving Application MSH.04 Receiving Application 30 R

Receiving Facility MSH.05 Receiving Facility 30 O

Message Date & Time MSH.06

Format: YYYYMMDDHHMMSS 14 O

Security MSH.07 Not Supported N

Message Type MSH.08 ORU^R01 R

Message Control ID MSH.09 A number that uniquely identifies the message O

Processing ID MSH.10 P-Production T-Test 1 O

Version ID MSH.11 2.x 8 O

Sample Output MSH|^~\&|ECW|TEST6600|1100|BN|200403021451||ORU^R01||P|2.3

PID – Patient Identification The Patient Identifier (PID) segment is used by all applications as the primary means of communicating patient identification information. This segment contains permanent patient identifying and demographic information that is not likely to change frequently:

Field Name Segment

Name Comment Len R/O

Segment Type ID PID.00 PID 3 R

Sequence Number PID.01 Serial Number starting from 1 4 R



Field Name Segment


Patient ID (Internal ID) PID.02 Patient ID 20 O

Patient ID (External ID) PID.03 Patient MRN 20 O

Alternate Patient ID PID.04 Not Supported N

Patient Name PID.05 Last Name 60^First Name 60^MI 60 180 R

Mother's Maiden Name PID.06 Not Supported N

Date of Birth PID.07 YYYYMMDD 8 R

Sex PID.08

F – Female M – Male U - Unknown 1 O

Patient Alias PID.09 Not Supported N

Race PID.10 Not Supported N

Patient Address PID.11 Addr1 60Âddr2 50^City 25^ State 10^Zip 12 161 O

County Code PID.12 Not Supported N

Phone number - Home PID.13 NNNNNNNNNN 10 O

Phone number - Business PID.14 Not Supported N

Primary Language PID.15 Not Supported N

Marital Status PID.16 Not Supported N

Religion PID.17 Not Supported N

PV1 – Patient Visit


Field Name Segment


Patient Account Number PID.18 Not Supported N

SSN # - Patient PID.19 NNNNNNNNN 9 O

Sample Output PID|1|7779|||Test^Test^||19670502|F||C|123 HIGH WAY^^Westboro^MA^01581|| 5085085085|||||32801465|999999999

PV1 – Patient Visit The PV1 segment is used to communicate information on a visit-specific basis and is not a required segment for the ORU Message:

Field Name Segment


Segment Type ID PV1.00 PV1 3 R

Sequence Number PV1.01 Serial number starting from 1 4 R

Patient Class PV1.02 Not supported N

Assigned Patient Location

PV1.03 Account Number O

Admission Type PV1.04 Not supported N

Pre-Admit Number PV1.05 Not supported N

Prior Patient Location

PV1.06 Not supported N

Attending Doctor PV1.07 Doctor Mnemonic 20 ^ Last Name 60^ FirstName 60 ^MI 60

200 R

ORC – Common Order Segment


Field Name Segment


Referring Provider PV1.08 Doctor Mnemonic 20 ^ Last Name 60^ FirstName 60 ^MI 60

200 O

Visit ID PV1.19 Customer Specific Accessioning 11 O

Sample Output PV1|1||110011||||C9999^TEST^DOCTOR^L|G8888^REF^PHY|||||||||||38808

ORC – Common Order Segment The Common Order (ORC) segment is used to receive fields that are common to all results in a given message (all types of services that are requested). The ORC segment is not required in the ORU message:

Field Name Segment


Segment Type ID ORC.00 ORC 3 R

Order Control ORC.01 Not Supported 4 N

Place Order Number ORC.02 Customer Specific Accessioning 11 R

Filler Order Number ORC.03 Not supported N

Placer Group Number ORC.04 Not supported N

Order Status ORC.05 Not supported N

Response Flag ORC.06 Not supported N

Quantity/Timing ORC.07 Not supported N

Parent ORC.08 Not supported N

OBR – Observation Request Segment


Field Name Segment


Date/Time of Transaction ORC.09 YYYYMMDDHHMMSS 14 O

Entered By ORC.10 Not supported N

Verified By ORC.11 Not supported N

Ordering Provider ORC.12 Doctor Mnemonic 20 ^ Last Name 60^FirstName 60 ^MI 60 200 R

Sample Output ORC|NW|38808|||||||200403021451|||C9999^TEST^TEST^L

OBR – Observation Request Segment At least one OBR segment should be present for each Order Code associated with any PID segment. This segment is mandatory in ORU messages:

Field Name Segment


Segment Type ID OBR.00 OBR 3 R

Sequence No OBR.01 Serial Number starting from 1 4 R

Placer Order Number OBR.02 Customer Specific Accessioning 20 R

Filler Order Number OBR.03 Vendor Report ID 35 R

Observation Battery Identifier OBR.04 Report Code 60^ReportName 180 240 R

Priority OBR.05 Not Supported N

Requested Date/Time OBR.06 Not Supported N

OBR – Observation Request Segment


Field Name Segment


Observation Date/Time # OBR.07

Observation Date/Time# Format YYYYMMDDHHMMSS 26 R

Observation End Date/Time # OBR.08 Not Supported N

Ordering Provider OBR.16 Doctor Mnemonic 20 ^ Last Name 60^FirstName 60 ^MI 60 200 R

Ordering Provider’s Phone Number OBR.17 Not Supported N

Alternate Specimen ID OBR.18 Alternate customer specific ID 40 O

Performing Lab OBR.23 Not Supported N

Report Status OBR.25 P – Preliminary F – Final 1 O

Sample Output OBR|1|38808||DS^Discharge Summary |||200402260900|||||||||C9999^Test^Test| |13005| ||||Company^12 Oak St ^^Seattle^WA^12345^^^||F|

OBX – Observation/Result Segment


OBX – Observation/Result Segment This segment can contain the textual report. If the textual report is sent in the NTE segments, the OBX segment is optional:

Field Name Segment


Segment Type ID OBX.00 OBX 3 R

Sequence Number OBX.01 Serial Number starting from 1 4 R

Type Value OBX.02 TX - Text 2 R

Observation Value OBX.05 Textual Report 200 R

Observation Result Status

OBX.11 P – Preliminary F – Final 1 O

Date Last Observation Normal Values

OBX.12 Not Supported N

User Defined Access Checks


Sample Output OBX|1|TX|||This is a Discharge Summary for Test, Test||||||F|||

NTE – Notes and Comments The Notes and Comments (NTE) segment contains the textual report, and is optional if the report is sent in the OBX segment:


Segment Type ID NTE.00 NTE 3 R

Sequence Number NTE.01 Serial Number starting from 1 4 R

Comment NTE.03 Textual Report 255 R

Sample 1 Report Message


Sample Output NTE|1| |This is a Discharge Summary for Test, Test|

Sample 1 Report Message MSH|^~\&|TEST|HEN|eClinicalWorks|TEST|200709171526||ORU|7|D|2.3|7

PID|||000145||TEST^TEST||19900202|M|^^^^^ÂÂ||^^^^|||||||00002527|

PV1||O|LAB||||12345^WILLIS^SAM|||||||||||REF|00002527|U||||||||||||||||||||||||200705100921|200705100921

OBR|1|23287||DS^Discharge Summary|||20010101|2007091715:21:00|||||||| 12345^WILLIS^SAM|||||||||||

OBX|1|TX||1| TEST REGIONAL HEALTH||||||||||

OBX|2|TX||1| ||||||||||

OBX|3|TX||1|_________________________________________________||||||||||

OBX|4|TX||1| CONFIDENTIAL REPORT||||||||||

OBX|5|TX||1| DISCHARGE SUMMARY DO NOT RE-RELEASE||||||||||

OBX|6|TX||1|_________________________________________________||||||||||

OBX|7|TX||1|CM:DISCHARGE NAME: TEST,TEST||||||||||

OBX|8|TX||1| ||||||||||

OBX|9|TX||1|cc. WILLIS, SAM||||||||||

OBX|10|TX||1| ||||||||||

OBX|11|TX||1|DICTATED BY: JOHN P SMITH, MD||||||||||

OBX|12|TX||1|DICTATED: 09/17/2007 AT 1522||||||||||

OBX|13|TX||1| ||||||||||

OBX|14|TX||1|ADMISSION DATE: 05/10/2007||||||||||

OBX|15|TX||1|DISCHARGE DATE: 05/12/2007||||||||||

OBX|16|TX||1| ||||||||||

OBX|17|TX||1|ADMITTING DIAGNOSIS: STOMATCH PAINS||||||||||

OBX|18|TX||1| ||||||||||

OBX|19|TX||1|DISCHARGE DIAGNOSIS: RELAXED, NO MORE PAIN||||||||||

OBX|20|TX||1| ||||||||||

OBX|21|TX||1|PRESENT ILLNESS: OKAY||||||||||

OBX|22|TX||1| ||||||||||

OBX|23|TX||1|PAST MEDICAL HISTORY: STRESSED||||||||||

OBX|24|TX||1| ||||||||||



OBX|25|TX||1|ALLERGIES: POLLEN||||||||||

OBX|26|TX||1| ||||||||||

OBX|27|TX||1|MEDICATIONS: NONE||||||||||

OBX|28|TX||1| ||||||||||

OBX|29|TX||1|SOCIAL HISTORY: NORMAL||||||||||

OBX|30|TX||1| ||||||||||

OBX|31|TX||1|FAMILY HISTORY: NONE||||||||||

OBX|32|TX||1| ||||||||||

OBX|33|TX||1|PHYSICAL EXAMINATION: OKAY||||||||||

OBX|34|TX||1| ||||||||||

OBX|35|TX||1|HOSPITAL COURSE: NA||||||||||

OBX|36|TX||1| ||||||||||

OBX|37|TX||1|LABORATORY FINDINGS: NEED TO DRINK PLENTY OF WATER|||||||

OBX|38|TX||1| ||||||||||

OBX|39|TX||1|DISCHARGE INSTRUCTIONS: REST AND TAKE A WEEK VACATION.|||

OBX|40|TX||1| ||||||||||

OBX|41|TX||1| ||||||||||

OBX|42|TX||1|________________________________________________||||||||||

OBX|43|TX||1|NAME: TEST,TEST||||||||||

OBX|44|TX||1|LOC: LAB ACC.#: 00002527 DIS SUM 1 of 1||||||||

OBX|45|TX||1|ROOM: UNIT#: 000145 ||||||||||

Sample 2 Report Message MSH|^~\&|TEST|HEN|eClinicalWorks|TEST|200709171526||ORU|7|D|2.3|7

PID|||000145||TEST^TEST||19900202|M|^^^^^ÂÂ||^^^^|||||||00002527|

PV1||O|LAB||||12345^WILLIS^SAM|||||||||||REF|00002527|U||||||||||||||||||||||||200705100921|200705100921

OBR|1|23287||DS^Discharge Summary|||20010101|2007091715:21:00|||||||| 12345^WILLIS^SAM|||||||||||

NTE|1|| TEST REGIONAL HEALTH|

NTE|2|||

NTE|3||_________________________________________________|

NTE|4|| CONFIDENTIAL REPORT|

NTE|5|| DISCHARGE SUMMARY DO NOT RE-RELEASE|

NTE|6||_________________________________________________|



NTE|7||CM:DISCHARGE NAME: TEST,TEST|

NTE|8|||

NTE|9||cc. WILLIS, SAM|

NTE|10||

NTE|11||DICTATED BY: JOHN P SMITH, MD|

NTE|12||DICTATED: 09/17/2007 AT 1522|

NTE|13||

NTE|14||ADMISSION DATE: 05/10/2007|

NTE|15||DISCHARGE DATE: 05/12/2007|

NTE|16||

NTE|17||ADMITTING DIAGNOSIS: STOMACH PAINS|

NTE|18||

NTE|19||DISCHARGE DIAGNOSIS: RELAXED, NO MORE PAIN|

NTE|20||

NTE|21||PRESENT ILLNESS: OKAY|

NTE|22||

NTE|23||PAST MEDICAL HISTORY: STRESSED|

NTE|24||

NTE|25||ALLERGIES: POLLEN

NTE|26||

NTE|27||MEDICATIONS: NONE||

NTE|28||

NTE|29||SOCIAL HISTORY: NORMAL|

NTE|30||

NTE|31||FAMILY HISTORY: NONE|

NTE|32||

NTE|33||PHYSICAL EXAMINATION: OKAY|

NTE|34||

NTE|35||HOSPITAL COURSE: NA|

NTE|36||

NTE|37||LABORATORY FINDINGS: NEED TO DRINK PLENTY OF WATER|

NTE|38||

NTE|39||DISCHARGE INSTRUCTIONS: REST AND TAKE A WEEK VACATION.|

NTE|40||

NTE|41||

NTE|42||________________________________________________|



NTE|43||NAME: TEST,TEST|

NTE|44||LOC: LAB ACC.#: 00002527 DIS SUM 1 of 1|

NTE|45||ROOM: UNIT#: 000145 |

Transaction Structure


HL7 REPORTS SPECIFICATIONS – MDM

The HL7 reports specifications (MDM) described in this section for eClinicalWorks are:

Transaction Structure PV1 – Patient Visit

Message Delimiters TXA – Document Notification Segment

Conventions MSH – Message Header Segment PID – Patient Identification

OBX – Observation/Result Segment NTE – Notes and Comments Sample 1 Report Message

Transaction Structure The following table outlines the transaction structure section of the HL7 message:

Name Description Comments

MSH Message Header This segment should always be present in the ORU message

EVN Event Type

PID Patient Identification There should be a PID segment to give the patient demographic information

PV1 Patient Visit PV1 segment if present will be used for determining the Physician Information

TXA Document Notification Contains information specific to a transcribed document

OBX Observation Result Report detail information is retrieved from this segment

NTE Notes and Comments Report detail information is retrieved from this segment

Message Delimiters


Message Delimiters The following table outlines the message delimiters:


Segment Terminator <CR> LF

Field Separator | (pipe)

Component Separator ^ (caret)

Repetition Separator ~ (tilde)

Conventions The following table outlines the conventions:


Required field – this should always be sent R

Optional field – this information will be processed if available O

Not Supported N

MSH – Message Header Segment The Message Header (MSH) segment defines the intent, source, destination, and some specifics of the syntax of a message:


Segment Type ID MSH.00 MSH 3 R

Encoding Characters MSH.01 ^~\& 4 R

Sending Application MSH.02 Sending Application 30 O




Sending Facility MSH.03 Sending Facility 30 O

Receiving Application MSH.04 Receiving Application 30 R

Receiving Facility MSH.05 Receiving Facility 30 O

Message Date & Time MSH.06

Format: YYYYMMDDHHMMSS 12 O

Security MSH.07 Not Supported N

Message Type MSH.08 MDM^T02 R

Message Control ID MSH.09 A number that uniquely identifies the message O

Processing ID MSH.10 P-Production T-Test 1 O

Version ID MSH.11 2.x 8 O

Sample Output MSH|^~\&|TEST|TEST|TEST||2009013012||MDM^T02|2009013012|P|2.3|

PID – Patient Identification The Patient Identifier (PID) segment is used by all applications as the primary means of communicating patient identification information. This segment contains permanent patient identifying and demographic information that is not likely to change frequently:

Field Name Segment


Segment Type ID PID.00 PID 3 R

Sequence Number PID.01 Serial Number starting from 1 4 R



Field Name Segment


Patient ID (Internal ID) PID.02 Patient ID 20 O

Patient ID (External ID) PID.03 Patient MRN O

Alternate Patient ID PID.04 Not Supported N

Patient Name PID.05 Last Name 60^First Name 60^MI 60 180 R

Mother's Maiden Name PID.06 Not Supported N

Date of Birth PID.07 YYYYMMDD 8 R

Sex PID.08

F – Female M – Male U - Unknown 1 O

Patient Alias PID.09 Not Supported N

Race PID.10 Not Supported N

Patient Address PID.11 Addr1 60Âddr2 50^City 25^ State 10^Zip 12 161 O

County Code PID.12 Not Supported N

Phone number - Home PID.13 NNNNNNNNNN 10 O

Phone number - Business PID.14 Not Supported N

Primary Language PID.15 Not Supported N

Marital Status PID.16 Not Supported N

Religion PID.17 Not Supported N

PV1 – Patient Visit


Field Name Segment


Patient Account Number PID.18 Not Supported N

SSN # - Patient PID.19 NNNNNNNNN 9 O

Sample Output PID|1|7779|||Test^Test^||19670502|F||C|123 HIGH WAY^^Westboro^MA^01581|| 5085085085|||||32801465|999999999

PV1 – Patient Visit The PV1 segment is used to communicate information on a visit-specific basis and is not a required segment for the ORU Message:

Field Name Segment


Segment Type ID PV1.00 PV1 3 R

Sequence Number PV1.01 Serial number starting from 1 4 R

Patient Class PV1.02 Not supported N

Assigned Patient Location

PV1.03 Account Number O

Admission Type PV1.04 Not supported N

Pre-Admit Number PV1.05 Not supported N

Prior Patient Location

PV1.06 Not supported N

Attending Doctor PV1.07 Provider Code 20^Last Name 60^FirstName 60 ^MI 60

200 R

TXA – Document Notification Segment


Field Name Segment


Referring Provider PV1.08 Provider Code 20^Last Name 60^FirstName 60 ^MI 60

200 O

Visit ID PV1.19 Customer Specific Accessioning 11 O

Sample Output PV1|1||110011||||C9999^TEST^DOCTOR^L|G8888^REF^PHY|||||||||||38808

TXA – Document Notification Segment The TXA segment contains information specific to a transcribed document but does not include the text of the document:

Field Name Segment


Segment Type ID TXA.00 TXA 3 R

Sequence No TXA.01 Serial Number starting from 1 4 R

Document Type TXA.02 Test Code 60^TestName 255 315 R

Document Content Presentation TXA.03 Not Supported N

Activity Date/Time TXA.04 YYYYMMDDHHMMSS 14 O

Primary Activity Provider Code/Name TXA.05

Provider Code 20^Last name 60^FirstName 60 ^MI 60 200 R

Origination Date/Time TXA.06 YYYYMMDDHHMMSS 26 O

Transcription Date/Time TXA.07 YYYYMMDDHHMMSS 26 O

TXA – Document Notification Segment


Field Name Segment


Edit Date/Time TXA.08 Not Supported N

Originator Code/Name TXA.09 Not Supported N

Assigned Document Authenticator TXA.10 Not Supported N

Transcriptionist Code/Name TXA.11 Not Supported N

Unique Document Number TXA.12 Unique identifier number 35 R

Document Completion Status TXA.17 Not Supported N

Document Confidentiality Status TXA.18 Not Supported N

Document Availability Status TXA.19 Not Supported N

Document Storage Status TXA.20 Not Supported N

Document Change Reason TXA.21 Not Supported N

Authentication Person, Time Stamp TXA.22 Not Supported N

Distributed Copies TXA.23 Not Supported N

Sample Output TXA|1|HP^History &

Physical|TX|200901151010|123^WILLIS^SAM||||||||||||DO||AV|

OBX – Observation/Result Segment


OBX – Observation/Result Segment This segment can contain the textual report. If the textual report is sent in the NTE segments, the OBX segment is optional:

Field Name Segment


Segment Type ID OBX.00 OBX 3 R

Sequence Number OBX.01 Serial Number starting from 1 4 R

Type Value OBX.02 TX - Text 2 R

Observation Value OBX.05 Textual Report 200 R

Observation Result Status

OBX.11 P – Preliminary F – Final 1 O

Date Last Observation Normal Values


User Defined Access Checks


Sample Output OBX|1|TX|||This is a Discharge Summary for Test, Test||||||F|||

NTE – Notes and Comments The Notes and Comments (NTE) segment contains the textual report, and is optional if the report is sent in the OBX segment:


Segment Type ID NTE.00 NTE 3 R

Sequence Number NTE.01 Serial Number starting from 1 4 R

Comment NTE.03 Textual Report 255 R



Sample Output NTE|1| |This is a Discharge Summary for Test, Test|

Sample 1 Report Message MSH|^~\&|TEST|TEST|Practice Partner||20090130123||MDM^T02|20090130123|P|2.3|||NE|

EVN|T02|200901301235|

PID|||||test^test||19920115|M||||||||||G83186|009729488|

PV1||1|CE||||12345^WILLIS^SAM^H|||||||||||

TXA|1|HP^History & Physical|TX|200901151010|||||||||||||DO||AV|

OBX|1|TX||| TEST HOSPITAL||||||P||||||

OBX|2|TX||| Morrisville, Vermont 05661||||||P||||||

OBX|3|TX||| HISTORY & PHYSICAL||||||P||||||

OBX|4|TX|||Name: TEST,TEST Sex: M Room #: 039A||||||P||||||

OBX|5|TX|||MR #: 123006 Age: 19 Acct. #: G8318||||||P

OBX|6|TX|||Physician:JAMES CLEA DOB: 07/13/1989 Admit Date:01/13/09||||||P||||||

OBX|7|TX|||Physician: KAEDING J Stay Type: I/P D/C||||||P||||||

OBX|8|TX|||Physician: KEITH P||||||P||||||

OBX|9|TX|||CC: Dizziness and weakness with elevated sugars.||||||P|||

OBX|10|TX|||HPI: This is a 19-year-old man with multiple admissions for poorly controlled||||||P||||||

OBX|11|TX||| insulin dependent diabetes mellitus||||||P||||||

OBX|12|TX|||and diabetic ketoacidosis who also has a history of elevated liver function te||||||P||||||

OBX|13|TX|||sts with his episodes of diabetic||||||P||||||

OBX|14|TX|||ketoacidosis over the last year. He saw his primary care doctor several times||||||P||||||

OBX|15|TX|||in the last week with increasing||||||P||||||

OBX|16|TX|||dizziness and weakness and came to the emergency room on the day of admission||||||P||||||

OBX|17|TX|||complaining of dizziness,||||||P||||||

OBX|18|TX|||vertigo, nausea, and inability to keep fluids down well. He complained of myal||||||P||||||

OBX|19|TX|||gias diffusely. He has had these||||||P||||||

OBX|20|TX|||symptoms over the last month but they have been worsening recently. He had the||||||P||||||



OBX|21|TX||| stomach flu prior to the onset of||||||P||||||

OBX|22|TX|||these symptoms and stated that it felt like it never really went away. In the||||||P||||||

OBX|23|TX|||emergency room, he had no episodes of||||||P||||||

OBX|24|TX|||emesis and drank 4 ginger ales, 5 milks, and ate an entire supper tray with no||||||P||||||

OBX|25|TX||| difficulties. His blood sugar was 216||||||P||||||

OBX|26|TX|||on admission. He states that his sugars have been mildly elevated recently but||||||P||||||

OBX|27|TX||| not critically high. He denies any||||||P||||||

OBX|28|TX|||non compliance with his medications recently. He denies any cough, any fevers,||||||P||||||

OBX|29|TX||| any rash, any sick contacts, any||||||P||||||

OBX|30|TX|||diarrhea or vomiting. He does state that his house is very cold because they a||||||P||||||

OBX|31|TX|||re keeping the heat down to conserve||||||P||||||

OBX|32|TX|||costs. They do have a wood stove which he spends most of his day keeping going||||||P||||||

OBX|33|TX|||. He is unemployed for the last 3||||||P||||||

OBX|34|TX|||to 4 months and spends all his day at the home of his roommate keeping the sto||||||P||||||

OBX|35|TX|||ve going. He has no method for||||||P||||||

OBX|36|TX|||transportation and he and his roommate live on food stamps that Tyler gets. He||||||P||||||

OBX|37|TX||| has no other spending money or||||||P||||||

OBX|38|TX|||savings. He states it is impossible to find a job in this current economy.||||||P||||||

OBX|39|TX|||PMH:||||||P||||||

OBX|40|TX||| 1. Type 1 diabetes mellitus since age 7 with frequent admissions for diabeti||||||P||||||

OBX|41|TX|||c ketoacidosis.||||||P||||||

OBX|42|TX||| 2. Depression and psychosocial stressors.||||||P||||||

OBX|43|TX||| 3. Elevated liver function tests with his episodes of diabetic ketoacidosis||||||P||||||

OBX|44|TX|||of unclear etiology.||||||P||||||

OBX|45|TX|||MEDICATIONS: Lantus 25 units subcu. each a.m. and 25 units subcu. each p.m.;||||||P||||||

OBX|46|TX|||NovoLog sliding scale as per||||||P||||||

OBX|47|TX|||his carbohydrate calculations; Protonix 40 mg daily; fluoxetine 10 mg daily; Z||||||P||||||



OBX|48|TX|||ofran p.r.n.||||||P||||||

OBX|49|TX|||ALLERGIES: LATEX, DROPERIDOL, PHENERGAN, PHISO-HEX, SHELLFISH, PEACHES, PITTE||||||P||||||

OBX|50|TX|||D||||||P||||||

OBX|51|TX|||FRUITS, PEANUT PRODUCTS.||||||P||||||

OBX|52|TX|||FH: He has a younger brother who is healthy. His mother has alcoholism and po||||||P||||||

OBX|53|TX|||ssible schizophrenia. His father||||||P||||||

OBX|54|TX|||has a history of alcohol abuse in the past. There are some family members with||||||P||||||

OBX|55|TX||| type 2 diabetes.||||||P||||||

OBX|56|TX|||SH: He lives with his mother's ex-boyfriend, Matt, and has been in his house||||||P||||||

OBX|57|TX|||for the last year and a half. Matt||||||P||||||

OBX|58|TX|||pays the bills but Tyler pays for their food with his food stamps for which ge||||||P||||||

OBX|59|TX|||ts approximately $175 a month. He||||||P||||||

OBX|60|TX|||lost his job at Concept II several months ago and has not been able to find an||||||P||||||

OBX|61|TX|||y employment. Part of his difficulty is||||||P||||||

OBX|62|TX|||transportation. He does not smoke cigarettes, drink alcohol or use any drugs.||||||P||||||

OBX|63|TX|||PSH: None.||||||P||||||

OBX|64|TX|||"Unsigned transcriptions represent a preliminary report and do not reflect a m||||||P||||||

OBX|65|TX|||edical or legal document"||||||P||||||

Appendix: Notices


Appendix: Notices

Trademarks eClinicalWorks®

eClinicalWorks is a trademark of eClinicalWorks, LLC.

All other trademarks or service marks contained herein are the property of their respective owners.

Documents

eCLINICALWORKS HL7 R SPECIFICATION · The following table outlines the transaction structure section of the HL7 message: ... PID|1|7779|||Test^Test^||19670502|F||C|123 HIGH WAY^^Westboro^MA^01581||